The Critically Ill Patient

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The Critically Ill Patient
Stuart Conquer Advanced Physiotherapist
Paediatric ICU, Surgery Medicine Sheffield
Childrens Hospital
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Aims of session

• Recap of essentials of assessment
• Respiratory Failure
• Auscultation
• CXR
• FBC
• Review of treatment options
• Positioning
• Breathing Techniques
• Secretion clearance
• Adjuncts
• On call
• Case Studies
• Appropriate/inappropriate
• Questions to ask

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Assessment
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Definitions

• Ventilation
• Respiratory Failure

• Ventilation is the drive to get CO2 out not to
  get O2 in

• An inability to sufficiently eliminate carbon
  dioxide from, or provide oxygen to the organ
  systems during spontaneous respiration.
• Cant get oxygen in
• /-
• Cant get carbon dioxide out

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Respiratory Failure
Type I Type II

• Inability to get oxygen in
• Hypoxaemia
• Cardiac
• Resp

• Inability to get carbon dioxide out
• Hypercapnoea
• Causes

• Pulmonary Oedema
• Embolism

• Pneumonia
• Asthma
• ARDS
• Fibrosis

• Airway obstruction
• Chest injury
• Neurological lesions
• Muscle/neuromuscular junction problems
• Chronic lung disease

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Auscultation
Thyroid cartilage
Cricoid cartilage
Tracheal cartilage
Right upper lobe
Left upper lobe
Left main bronchus
Right main bronchus
Horizontal fissure
Oblique fissure
Right middle lobe
Oblique fissure
Bronchioles
Right lower lobe
Left lower lobe
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Auscultation

• Bronchial
• Vesicular

• Breath sounds
• Normal
• Equal
• Complete

• Crackles
• Inspiratory/Expiratory
• Coarse/Fine
• All or part
• Where is it?

• Wheeze
• Inspiratory/Expiratory
• All or part
• Monophonic/Polyphonic
• Where is it?

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Chest X-rays

• Be methodical
• Demographics
• Type of film
• Exposure
• Position
• Heart
• Lungs
• Ribs
• Anything Added

• Abnormal
• Too white
• Too Dark
• Too Big/small
• In the wrong place

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Left upper lobe Left lower lobe
Right upper lobe Right middle
lobe Right lower lobe
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Blood Count

• Hb
• WCC
• Royal Marines
• Royal Marine Commandos
• SAS
• SBS
• CRP

• Platelets
• Urea
• Creatinine
• Albumin
• Lactate
• Sodium
• Potassium
• Others at a later date if required

Neutrophils
Lymphocytes
Macrophages
Eosinophils
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Treatment
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Options

• Positioning
• Breathing Techniques
• Secretion Clearance Techniques
• Adjuncts
• BE METHODICAL

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On call
TREAT?
MANUAL TECHNIQUES?
RUN?
COMPUTER SAYS NO!
SLEEP
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Appropriate
Inappropriate
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Case Study 1

• Capt. C Caveman
• Retired Colonel BAF
• ICU admission with AAA repair (emergency)
• CV Instability post-op
• Reduced air entry L LZs
• Type I respiratory failure
• Secretion retention

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Case Study 2

• Ms P Pittstop
• Racing Driver
• Crash sustaining Ribs and pneumothorax L
• Blood Stained secretions
• Pain
• Oxygen requirement

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Case Study 3

• Mr H K Phooey
• Janitor (mild Mannered of course!)
• Keeps exotic birds
• Atypical pneumonia
• Increased WOB
• Secretion Retention

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Case Study 4

• Dame Crystal Tipps
• 85 year old millionaire
• Smokes 60 park-drive/day
• COPD
• Increased WOB
• Thick green secretions
• Type II respiratory failure

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